Page 1 of 19 POLICY This policy applies to The Johns Hopkins Health System Corporation (JHHS) following entities: The Johns Hopkins Hospital (JHH), Johns Hopkins Bayview Medical Center, Inc. Acute Care Hospital and Special Programs (JHBMC) and the Chronic Specialty Hospital of the Johns Hopkins Bayview Care Center (JHBCC). Purpose JHHS is committed to providing financial assistance to patients who have health care needs and are uninsured, underinsured, ineligible for a government program, or otherwise unable to pay, for medically necessary care based on their individual financial situation. It is the policy of the Johns Hopkins Medical Institutions to provide Financial Assistance based on indigence or excessive Medical Debt for patients who meet specified financial criteria and request such assistance. The purpose of the following policy statement is to describe how applications for Financial Assistance can be made, the criteria for eligibility, and the steps for processing each application. JHHS hospitals will publish the availability of Financial Assistance on a yearly basis in their local newspapers, and will post notices of availability at patient registration sites, Admissions/Business Office the Billing Office, and at the emergency department within each facility. Notice of availability will be posted on each hospital website, will be mentioned during oral communications, and will also be sent to patients on patient bills. A Patient Billing and Financial Assistance Information Sheet will be provided to inpatients before discharge and will be available to all patients upon request. Financial Assistance may be extended when a review of a patient s individual financial circumstances has been conducted and documented. Review for Medical Financial Hardship Assistance shall include a review of the patient s existing medical expenses and obligations (including any accounts placed in bad debt) and any projected medical expenses. Financial Assistance Applications and Medical Financial Hardship Assistance may be offered to patients whose accounts are with a collection agency and will apply only to those accounts on which a judgment has not been granted, so long as other requirements are met. FOR PHYSICIANS PROVIDING CARE NOTICE: Attached as EXHIBIT D is a list of physicians that provide emergency and medically necessary care as defined in this policy at JHH, JHBMC and JHBCC. The lists indicates if the doctor is covered under this policy. If the doctor is not covered under this policy, patients should contact the physician s office to determine if the physician offers financial assistance and if so what the physician s financial assistance policy provides. Definitions Medical Debt Medical Debt is defined as out of pocket expenses for medical costs resulting from medically necessary care billed by the Hopkins hospital to which the application is made. Out of pocket expenses do not include co-payments, co-insurance and deductibles unless the patient purchased insurance through a Qualified Health Plan and meets eligibility requirements. Medical Debt does not include those hospital bills for which the patient chose to be registered as Voluntary Self Pay (opting out of insurance coverage, or insurance billing).
Page 2 of 19 Liquid Assets Elective Admission Immediate Family Emergency Medical Condition Cash, securities, promissory notes, stocks, bonds, U.S. Savings Bonds, checking accounts, savings accounts, mutual funds, Certificates of Deposit, life insurance policies with cash surrender values, accounts receivable, pension benefits or other property immediately convertible to cash. A safe harbor of $150,000 in equity in patient s primary residence shall not be considered an asset convertible to cash. Equity in any other real property shall be subject to liquidation. Liquid Assets do not include retirement assets to which the Internal Revenue Service has granted preferential tax treatment as a retirement account, including but not limited to, deferred compensation plans qualified under the Internal Revenue Code or non qualified deferred compensation plans. A hospital admission that is for the treatment of a medical condition that is not considered an Emergency Medical Condition. If patient is a minor, immediate family member is defined as mother, father, unmarried minor siblings, natural or adopted, residing in the same household. If patient is an adult, immediate family member is defined as spouse or natural or adopted unmarried minor children residing in the same household. A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, or other acute symptoms such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (a) Serious jeopardy to the health of a patient; (b) Serious impairment of any bodily functions; (c) Serious dysfunction of any bodily organ or part. (d) With respect to a pregnant woman: 1. That there is inadequate time to effect safe transfer to another hospital prior to delivery. 2. That a transfer may pose a threat to the health and safety of the patient or fetus. 3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes. Emergency Services and Care Medically Necessary Care Medically Necessary Admission Medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine whether an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician which is necessary to relieve or eliminate the emergency medical condition, within the service capability of the hospital. Medical treatment that is necessary to treat an Emergency Medical Condition. Medically necessary care for the purposes of this policy does not include Elective or cosmetic procedures. A hospital admission that is for the treatment of an Emergency Medical Condition.
Page 3 of 19 Family Income Supporting Documentation Patient's and/or responsible party's wages, salaries, earnings, tips, interest, dividends, corporate distributions, rental income, retirement/pension income, Social Security benefits and other income as defined by the Internal Revenue Service, for all members of Immediate Family residing in the household. Pay stubs; W-2s; 1099s; workers' compensation, Social Security or disability award letters; bank or brokerage statements; tax returns; life insurance policies; real estate assessments and credit bureau reports, Explanation of Benefits to support Medical Debt. Qualified Health Plan Under the Affordable Care Act, starting in 2014, an insurance plan that is certified By the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximuim amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold. PROCEDURES 1. An evaluation for Financial Assistance can begin in a number of ways: For example: A patient with a self-pay balance due notifies the self-pay collector or collection agency that he/she cannot afford to pay the bill and requests assistance. A patient presents at a clinical area without insurance and states that he/she cannot afford to pay the medical expenses associated with their current or previous medical services. A patient with a hospital account referred to a collection agency notifies the collection agency that he/she cannot afford to pay the bill and requests assistance. A physician or other clinician refers a patient for Financial-Assistance evaluation for either inpatient or outpatient services. 2. Each Clinical or Business Unit will designate a person or persons who will be responsible for taking Financial Assistance applications. These staff can be Financial Counselors, Self-Pay Collection Specialists, Administrative staff, Customer Service, etc. 3. Designated staff will meet with patients who request Financial Assistance to determine if they meet preliminary criteria for assistance. a. All hospital applications will be processed within two business days and a determination will be made as to probable eligibility. To facilitate this process each applicant must provide information about family size and income, (as defined by Medicaid regulations). To help applicants complete the process, we will provide a statement of conditional approval that will let them know what paperwork is required for a final determination of eligibility. b. Applications received will be sent to the JHHS Patient Financial Services Department s dedicated Financial Assistance application line for review; a written determination of probable eligibility will be issued to the patient. 4. To determine final eligibility, the following criteria must be met:
Page 4 of 19 a. The patient must apply for Medical Assistance or insurance coverage through a Qualified Health Plan and cooperate fully with the Medical Assistance team or its designated agent, unless the financial representative can readily determine that the patient would fail to meet the eligibility requirements. The Patient Profile Questionnaire (Exhibit B) is used to determine if the patient must apply for Medical Assistance. In cases where the patient has active Medical Assistance pharmacy coverage or QMB coverage, it would not be necessary to reapply for Medical Assistance unless the financial representative has reason to believe that the patient may be awarded full Medical Assistance benefits. b. Consider eligibility for other resources, such as endowment funds, outside foundation resources, etc. c. The patient must be a United States of America citizen or permanent legal resident (must have resided in the U.S.A. for a minimum of one year). d. All insurance benefits must have been exhausted. 5. To the extent possible, there will be one application process for all of the Maryland hospitals of JHHS. The patient is required to provide the following: a. A completed Financial Assistance Application (Exhibit A) and Patient Profile Questionnaire (Exhibit B). b. A copy of their most recent Federal Income Tax Return (if married and filing separately, then also a copy of spouse s tax return and a copy of any other person's tax return whose income is considered part of the family income as defined by Medicaid regulations). c. A copy of the three (3) most recent pay stubs (if employed) or other evidence of income of any other person whose income is considered part of the family income as defined by Medicaid regulations. d. A Medical Assistance Notice of Determination (if applicable). e. Proof of U.S. citizenship or lawful permanent residence status (green card) if applicable. f. Proof of disability income (if applicable). g. Reasonable proof of other declared expenses. h. If unemployed, reasonable proof of unemployment such as statement from the Office of Unemployment Insurance, a statement from current source of financial support, etc... 6. A patient can qualify for Financial Assistance either through lack of sufficient insurance or excessive Medical Debt. Medical Debt is defined as out of pocket expenses excluding copayments, coinsurance and deductibles unless the patient purchased insurance through a Qualified Health Plan and meets eligibility requirements for medical costs billed by a Hopkins hospital. Once a patient has submitted all the required information, the Financial Counselor will review and analyze the application and forward it to the Patient Financial Services Department for final determination of eligibility based upon JHMI guidelines. a. If the application is denied, the patient has the right to request the application be reconsidered. The Financial Counselor will forward the application and attachments to the Financial
Page 5 of 19 Assistance Evaluation Committee for final evaluation and decision. b. If the patient s application for Financial Assistance is based on excessive Medical Debt or if there are extenuating circumstances as identified by the Financial Counselor or designated person, the Financial Counselor will forward the application and attachments to the Financial Assistance Evaluation Committee. This committee will have decision-making authority to approve or reject applications. It is expected that an application for Financial Assistance reviewed by the Committee will have a final determination made no later than 30 days from the date the application was considered complete. The Financial Assistance Evaluation Committee will base its determination of financial need on JHHS guidelines. 7. Each clinical department has the option to designate certain elective procedures for which no Financial Assistance options will be given. 8. Services provided to patients registered as Voluntary Self Pay patients do not qualify for Financial Assistance. 9. A department operating programs under a grant or other outside governing authority (i.e., Psychiatry) may continue to use a government-sponsored application process and associated income scale. 10. Once a patient is approved for Financial Assistance, Financial Assistance coverage shall be effective for the month of determination and the following six (6) calendar months. If patient is approved for a percentage allowance due to financial hardship it is recommended that the patient make a good-faith payment at the beginning of the Financial Assistance period. Upon a request from a patient who is uninsured and whose income level falls within the Medical Financial Hardship Income Grid set forth in Appendix B, JHHS shall make a payment plan available to the patient. Any payment schedule developed through this policy will ordinarily not last longer than two years. In extraordinary circumstances and with the approval of the designated manager a payment schedule may be extended. 11. Presumptive Financial Assistance Eligibility. There are instances when a patient may appear eligible for financial assistance, but there is no financial assistance form on file. Often there is adequate information provided by the patient or other sources, which could provide sufficient evidence to provide the patient with financial assistance. In the event there is no evidence to support a patient s eligibility for financial assistance, JHHS reserves the right to use outside agencies in determining estimated income amounts for the basis of determining financial assistance eligibility and potential reduced care rates. Once determined, due to the inherent nature of presumptive circumstances, the only financial assistance that can be granted is a 100% write-off of the account balance. Presumptive Financial Assistance Eligibility shall only cover the patient s specific date of service and shall not be effective for a six (6) month period. Presumptive eligibility may be determined on the basis of individual life circumstances. Unless otherwise eligible for Medicaid or CHIP, patients who are beneficiaries/recipients of the means-tested social service programs listed by the Health Services Cost Review Commission in COMAR 10.37.10.26 A-2 are deemed Presumptively Eligible for free care provided the patient submits proof of enrollment within 30 days of date of service. Such 30 days may be extended to 60 days if patient or patient s representative request an additional 30 days. Appendix A-1 provides a list of life circumstances in addition to those specified by the regulations listed above that qualify a patient for Presumptive Eligibility. 12. Financial Assistance Applications may only be submitted for/by patients with open and unpaid hospital accounts. 13. Patients who indicate they are unemployed and have no insurance coverage shall be required to submit a Financial Assistance Application unless they meet Presumptive Financial Assistance
Page 6 of 19 Eligibility criteria. If patient qualifies for COBRA coverage, patient s financial ability to pay COBRA insurance premiums shall be reviewed by the Financial Counselor and recommendations shall be made to Financial Assistance Evaluation Committee. Individuals with the financial capacity to purchase health insurance shall be encouraged to do so, as a means of assuring access to health care services and for their overall personal health. 14. Patients who receive coverage on a Qualified Health Plan and ask for help with out of pocket expenses (co-payments and deductibles) for medical costs resulting from medically necessary care shall be required to submit a Financial Assistance Application if the patient is at or below 200% of Federal Poverty Guidelines. 15. If a patient account has been assigned to a collection agency, and patient or guarantor request financial assistance or appears to qualify for financial assistance, the collection agency shall notify PFS and shall forward the patient/guarantor a financial assistance application with instructions to return the completed application to PFS for review and determination and shall place the account on hold for 45 days pending further instruction from PFS. 16. Beginning October 1, 2010, if within a two (2) year period after the date of service a patient is found to be eligible for free care on the date of service (using the eligibility standards applicable on the date of service), the patient shall be refunded amounts received from the patient/guarantor exceeding $25. If the hospital documentation demonstrates the lack of cooperation of the patient or guarantor in providing information to determine eligibility for free care, the two (2) year period herein may be reduced to 30 days from the date of initial request for information. If the patient is enrolled in a means-tested government health care plan that requires the patient to pay-out-of pocket for hospital services, then patient or guarantor shall not be refunded any funds that would result in patient losing financial eligibility for health coverage. 17. This Financial Assistance policy does not apply to deceased patients for whom a decedent estate has or should be opened due to assets owned by a deceased patient. Johns Hopkins will file a claim in the decedents estate and such claim will be subject to estate administration and applicable Estates and Trust laws. 18. JHHS Hospitals may extend Financial Assistance to residents with demonstrated financial need, regardless of citizenship, in the neighborhoods surrounding their respective hospitals, as determined by the hospital s Community Health Needs Assessment. The zip codes for JHH and JHBMC are: 21202, 21205, 21206, 21213, 21218, 21219, 21222, 21224, 21231 and 21052. Once a patient is approved for Financial Assistance, Financial Assistance coverage shall be effective for the month of determination and the following six (6) calendar months. Financial Counselors will refer these patients to The Access Partnership program at Hopkins (see FIN057 for specific procedures). REFERENCE 1 JHHS Finance Policies and Procedures Manual Policy No. FIN017 - Signature Authority: Patient Financial Services Policy No. FIN033 - Installment Payments Charity Care and Bad Debts, AICPA Health Care Audit Guide 1 1 NOTE: Standardized applications for Financial Assistance, Patient Profile Questionnaire and Medical Financial Hardship have been developed. For information on ordering, please contact the Patient Financial Services Department. Copies are attached to this policy as Exhibits A, B and C.
Page 7 of 19 Code of Maryland Regulations COMAR 10.37.10.26, et seq Maryland Code Health General 19-214, et seq Federal Poverty Guidelines (Updated annually) in Federal Register RESPONSIBILITIES - JHH, JHBMC Financial Counselor (Pre- Admission/Admission/In-House/ Outpatient) Customer Service Collector Admissions Coordinator Any Finance representative designated to accept applications for Financial Assistance Understand current criteria for Assistance qualifications. Identify prospective patients; initiate application process when required. As necessary assist patient in completing application or program specific form. On the day preliminary application is received, fax to Patient Financial Services Department s dedicated fax line for determination of probable eligibility. Review preliminary application, Patient Profile Questionnaire and Medical Financial Hardship Application (if submitted) to make probable eligibility determination. Within two business days of receipt of preliminary application, mail determination to patient s last known address or deliver to patient if patient is currently an inpatient. Notate patient account comments. If Financial Assistance Application is not required, due to patient meeting specific criteria, notate patient account comments and forward to Management Personnel for review. Review and ensure completion of final application. Deliver completed final application to appropriate management. Document all transactions in all applicable patient accounts comments. Identify retroactive candidates; initiate final application process.
Page 8 of 19 Management Personnel (Supervisor/Manager/Director) Review completed final application; monitor those accounts for which no application is required; determine patient eligibility; communicate final written determination to patient within 30 business days of receiving completed application. If patient is eligible for reduced cost care, apply the most favorable reduction in charges for which patient qualifies. Advise ineligible patients of other alternatives available to them including installment payments, bank loans, or consideration under the Medical Financial Hardship program if they have not submitted the supplemental application, Exhibit C. [Refer to Appendix B - Medical Financial Hardship Assistance Guidelines.] Notices will not be sent to Presumptive Eligibility recipients. Financial Management Personnel (Senior Director/Assistant Treasurer or affiliate equivalent) CP Director and Management Staff Review and approve Financial Assistance applications and accounts for which no application is required and which do not write off automatically in accordance with signature authority established in JHHS Finance Policy No. FIN017 - Signature Authority: Patient Financial Services. SPONSOR Senior Director, Patient Finance (JHHS) Director, PFS Operations (JHHS) REVIEW CYCLE Two (2) years APPROVAL Sr. VP of Finance/Treasurer & CFO for JHH and JHHS Date
Page 9 of 19 APPENDIX A PROGRAM ELIGIBILITY GUIDELINES 1. Each patient requesting Financial Assistance must complete a JHM/Financial Assistance Application (also known as the Maryland State Uniform Financial Assistance Application) Exhibit A, and Patient Profile Questionnaire, Exhibit B. If patient wishes to be considered for Medical Financial Hardship, patient must submit Medical Financial Hardship Application, Exhibit C. 2. A preliminary application stating family size and family income (as defined by Medicaid regulations) will be accepted and a determination of probable eligibility will be made within two business days of receipt. 3. The patient must apply for Medical Assistance or insurance coverage through a Qualified Health Plan and cooperate fully with the Medical Assistance team or its designated agent, unless the financial representative can readily determine that the patient would fail to meet the eligibility requirements. A Patient Profile Questionnaire (see Exhibit B) has been developed to determine if the patient must apply for Medical Assistance. In cases where the patient has active Medical Assistance pharmacy coverage or QMB coverage, it would not be necessary to reapply for Medical Assistance unless the financial representative has reason to believe that the patient may be awarded full Medical Assistance benefits. 4. The patient must be a United States of America citizen or permanent legal resident (must have resided in the U.S.A. for a minimum of one year) 5. Proof of income must be provided with the final application. Acceptable proofs include: (a) Prior-year tax return; (b) Current pay stubs; (c) Letter from employer, or if unemployed documentation verifying unemployed status; and (d) A credit bureau report obtained by the JHM affiliates and/or Patient Financial Services Department. 6. Patients will be eligible for Financial Assistance if their maximum family (husband and wife, same sex married couples) income (as defined by Medicaid regulations) level does not exceed each affiliate s standard (related to the Federal poverty guidelines) and they do not own Liquid Assets *in excess of $10,000 which would be available to satisfy their JHHS affiliate bills. 7. All financial resources must be used before the Financial Assistance can be applied. This includes insurance, Medical Assistance, and all other entitlement programs for which the patient may qualify. 8. Patients who chose to become voluntary self pay patients do not qualify for Financial Assistance for the amount owed on any account registered as Voluntary Self Pay. 9. Financial Assistance is only applicable to Medically Necessary Care as defined in this policy. Financial Assistance is not applicable to convenience items, private room accommodations or nonessential cosmetic surgery. Non-hospital charges will remain the responsibility of the patient. In the event a question arises as to whether an admission is an "Elective Admission" or a "Medically Necessary Admission," the patient's admitting physician shall be consulted and the matter will also be directed to the physician advisor appointed by the hospital. 10. Each affiliate will determine final eligibility for Financial Assistance within thirty (30) business days of the day when the application was satisfactorily completed and submitted.
Page 10 of 19 11. Documentation of the final eligibility determination will be made on all (open-balance) patient accounts. A determination notice will be sent to the patient. 12. A determination of eligibility for Financial Assistance based on the submission of a Financial Assistance Application will remain valid for a period of six (6) months for all necessary JHM affiliate services provided, based on the date of the determination letter. Patients who are currently receiving Financial Assistance from one JHM affiliate will not be required to reapply for Financial Assistance from another affiliate. 13. All determinations of eligibility for Financial Assistance shall be solely at the discretion of the JHHS affiliate. Exception The Director of Patient Financial Services (or affiliate equivalent) may make exceptions according to individual circumstances.
Page 11 of 19 FREE OR REDUCED COST CARE GRID TABLE FOR DETERMINATION OF ALLOWANCES Effective 3/1/16 # of Persons in Family Income Level* Upper Limits of Income for Allowance Range 1 $ 23,760 $ 26,136 $ 28,512 $ 30,888 $ 33,264 $ 35,640 2 $ 32,040 $ 35,244 $ 38,448 $ 41,652 $ 44,856 $ 48,060 3 $ 40,320 $ 44,352 $ 48,384 $ 52,416 $ 56,448 $ 60,480 4 $ 48,600 $ 53,460 $ 58,320 $ 63,180 $ 68,040 $ 72,900 5 $ 56,880 $ 62,568 $ 68,256 $ 73,944 $ 79,632 $ 85,320 6 $ 65,160 $ 71,676 $ 78,192 $ 84,708 $ 91,224 $ 97,740 7 $ 73,460 $ 80,806 $ 88,152 $ 95,498 $ 102,844 $ 110,190 8* $ 81,780 $ 89,958 $ 98,136 $ 106,314 $ 114,492 $ 122,670 **amt for each mbr $8,320 $9,152 $9,984 $10,816 $11,648 $12,480 Allow ance to Give: 100% 80% 60% 40% 30% 20% * 200% of Poverty Guidelines ** For family units with more than eight (8) members. EXAMPLE: Annual Family Income $55,000 # of Persons in Family 4 Applicable Poverty Income Level 48,600 Upper Limits of Income for Allowance Range $58,320 (60% range) ($55,000 is less than the upper limit of income; therefore patient is eligible for Financial Assistance.)
Page 12 of 19 Appendix A-1 Presumptive Financial Assistance Eligibility There are instances when a patient may appear eligible for financial assistance, but there is no financial assistance form on file. Often there is adequate information provided by the patient or through other sources, which could provide sufficient evidence to provide the patient with financial assistance. In the event there is no evidence to support a patient s eligibility for financial assistance, JHHS reserves the right to use outside agencies in determining estimate income amounts for the basis of determining financial assistance eligibility and potential reduced care rates. Once determined, due to the inherent nature of presumptive circumstances, the only financial assistance that can be granted is a 100% write off of the account balance. Presumptive Financial Assistance Eligibility shall only cover the patient s specific date of service and shall not be effective for a six (6) month period. Presumptive eligibility may be determined on the basis of individual life circumstances that may include: Active Medical Assistance pharmacy coverage QMB coverage/ SLMB coverage Homelessness Medical Assistance and Medicaid Managed Care patients for services provided in the ER beyond the coverage of these programs Maryland Public Health System Emergency Petition patients Participation in Women, Infants and Children Programs (WIC)* Supplemental Nutritional Assistance program (SNAP) or Food Stamp eligibility * Households with children in the free or reduced lunch program* Low-income household energy assistance program participation* Eligibility for other state or local assistance programs which have financial eligibility at or below 200% of FPL Patient is deceased with no known estate The Access Partnership Program at Hopkins (see FIN057 for specific procedures) Patients that are determined to meet eligibility criteria established under former State Only Medical Assistance Program The Pregnancy Care Program at JHBMC (see FIN053 for specific procedures) *These life circumstances are set forth in COMAR 10.37.10.26 A-2. The patient needs to submit proof of enrollment in these programs within 30 days of treatment unless the patient requests an additional 30 days.
Effective Date 4-1-16 Page 13 of 19 Supersedes 01-1-15 APPENDIX B MEDICAL FINANCIAL HARDSHIP ASSISTANCE GUIDELINES Purpose These guidelines are to provide a separate, supplemental determination of Financial Assistance. This determination will be offered to all patients who apply for Financial Assistance. Medical Financial Hardship Assistance is available for patients who are not eligible for Financial Assistance under the primary section of this policy, but for whom: 1.) Medical Debt incurred over a twelve (12) month period exceeds 25% of the Family Income creating Medical Financial Hardship; and 2.) who meet the income standards for this level of Assistance. For those patients who are eligible for reduced cost care under the Financial Assistance criteria and also qualify under the Medical Financial Hardship Assistance Guidelines, JHHS shall apply the reduction in charges that is most favorable to the patient. Medical Financial Hardship is defined as Medical Debt for medically necessary treatment incurred by a family over a twelve (12) month period that exceeds 25% of that family s income. Medical Debt is defined as out of pocket expenses for medical costs for Medically Necessary Care billed by the Hopkins hospital to which the application is made, the out of pocket expenses mentioned above do not include co-payments, co-insurance and deductibles, unless the patient is below 200% of Federal Poverty Guidelines. The patient/guarantor can request that such a determination be made by submitting a Medical Financial Hardship Assistance Application (Exhibit C), when submitting JHM/Financial Assistance Application, also known as the Maryland State Uniform Financial Assistance Application (Exhibit A), and the Patient Profile Questionnaire (Exhibit B). The patient guarantor must also submit financial documentation of family income for the twelve (12) calendar months preceding the application date and documentation evidencing Medical Debt of at least 25% of family income. Once a patient is approved for Medical Hardship Financial Assistance, Medical Hardship Financial Assistance coverage shall be effective starting the month of the first qualifying service and the following twelve (12) calendar months. It shall cover those members of the patient s Immediate Family residing in the same household. The patient and the Immediate Family members shall remain eligible for reduced cost Medically Necessary Care when seeking subsequent care at the same hospital for twelve (12) calendar months beginning on the date on which the reduced cost Medically Necessary Care was initially received. Coverage shall not apply to Elective Admissions or Elective or cosmetic procedures. However, the patient or the patient s immediate family member residing in the same household must notify the hospital of their eligibility for the reduced cost medically necessary care at registration or admission. General Conditions for Medical Financial Hardship Assistance Application: 1. Patient s income is under 500% of the Federal Poverty Level. 2. Patient has exhausted all insurance coverage. 3. Patient account balances for patients who chose to register as voluntary self pay shall not counted toward Medical Debt for Medical Financial Hardship Assistance. 4. Patient/guarantor do not own Liquid Assets *in excess of $10,000 which would be available to satisfy their JHHS affiliate bills. 5. Patient is not eligible for any of the following: Medical Assistance
Effective Date 4-1-16 Page 14 of 19 Supersedes 01-1-15 Other forms of assistance available through JHM affiliates 6. Patient is not eligible for The JHM Financial Assistance Program or is eligible but the Medical Financial Hardship Program may be more favorable to the patient. 7. The affiliate has the right to request patient to file updated supporting documentation. 8. The maximum time period allowed for paying the amount not covered by Financial Assistance is three (3) years. 9. If a federally qualified Medicaid patient required a treatment that is not approved by Medicaid but may be eligible for coverage by the Medical Financial Hardship Assistance program, the patient is still required to file a JHHS Medical Financial Hardship Assistance Application but not to submit duplicate supporting documentation. Factors for Consideration The following factors will be considered in evaluating a Medical Financial Hardship Assistance Application: Medical Debt incurred over the twelve (12) months preceding the date of the Financial Hardship Assistance Application at the Hopkins treating facility where the application was made. Liquid Assets (leaving a residual of $10,000) Family Income for the twelve (12) calendar months preceding the date of the Financial Hardship Assistance Application Supporting Documentation Exception The Director or designee of Patient Financial Services (or affiliate equivalent) may make exceptions according to individual circumstances. Evaluation Method and Process 1. The Financial Counselor will review the Medical Financial Hardship Assistance Application and collateral documentation submitted by the patient/responsible party. 2. The Financial Counselor will then complete a Medical Financial Hardship Assistance Worksheet (found on the bottom of the application) to determine eligibility for special consideration under this program. The notification and approval process will use the same procedures described in the Financial Assistance Program section of this policy.
Effective Date 4-1-16 Page 15 of 19 Supersedes 01-1-15 MEDICAL HARDSHIP FINANCIAL GRID Upper Limits of Family Income for Allowance Range TABLE FOR DETERMINATION OF ALLOWANCES # of Persons in Family # of Persons in Family Effective 3/1/16 Income Level** 300% of FPL 400% of FPL 500% of FPL 1 $ 35,640 $ 47,520 $ 59,400 2 $ 48,060 $ 64,080 $ 80,100 3 $ 60,480 $ 80,640 $ 100,800 4 $ 72,900 $ 97,200 $ 121,500 5 $ 85,320 $ 113,760 $ 142,200 6 $ 97,740 $ 130,320 $ 162,900 7 $ 110,190 $ 146,920 $ 183,650 8* $ 122,670 $ 163,560 $ 204,450 Allow ance to Give: 50% 35% 20% *For family units with more than 8 members, add $12,480 for each additional person at 300% of FPL, $16,640 at 400% at FPL; and $20,800 at 500% of FPL.
Exhibit A Johns Hopkins 3910 Keswick Road, Suite S-5100 Baltimore, MD 21211
Exhibit A
Effective Date 4-1-16 Page 18 of 19 Supersedes 01-1-15 EXHIBIT B PATIENT FINANCIAL SERVICES PATIENT PROFILE QUESTIONNAIRE HOSPITAL NAME: PATIENT NAME: PATIENT ADDRESS: (Include Zip Code) MEDICAL RECORD #: 1. What is the patient s age? 2. Is the patient a U.S. citizen or permanent resident? Yes or No 3. Is patient pregnant? Yes or No 4. Does patient have children under 21 years of age living at home? Yes or No 5. Is patient blind or is patient potentially disabled for 12 months or more from gainful employment? Yes or No 6. Is patient currently receiving SSI or SSDI benefits? Yes or No 7. Does patient (and, if married, spouse) have total bank accounts or assets convertible to cash that do not exceed the following amounts? Yes or No Family Size: Individual: $2,500.00 Two people: $3,000.00 For each additional family member, add $100.00 (Example: For a family of four, if you have total liquid assets of less than $3,200.00, you would answer YES.) 8. Is patient a resident of the State of Maryland? Yes or No If not a Maryland resident, in what state does patient reside? 9. Is patient homeless? Yes or No 10. Does patient participate in WIC? Yes or No 11. Does household have children in the free or reduced lunch program? Yes or No 12. Does household participate in low-income energy assistance program? Yes or No 13. Does patient receive SNAP/Food Stamps? Yes or No 14. Is the patient enrolled in Healthy Howard and referred to JHH Yes or No 15. Does patient currently have? Medical Assistance Pharmacy Only Yes or No QMB coverage/ SLMB coverage Yes or No 16. Is patient employed? Yes or No If no, date became unemployed. Eligible for COBRA health insurance coverage? Yes or No
Effective Date 4-1-16 Page 19 of 19 Supersedes 01-1-15 EXHIBIT C MEDICAL FINANCIAL HARDSHIP APPLICATION HOSPITAL NAME: PATIENT NAME: PATIENT ADDRESS: (Include Zip Code) MEDICAL RECORD #: Date: Family Income for twelve (12) calendar months preceding date of this application: Medical Debt incurred at The Johns Hopkins Hospital (not including co-insurance, co-payments, or deductibles) for the twelve (12) calendar months preceding the date of this application: Date of service Amount owed All documentation submitted becomes part of this application. All the information submitted in the application is true and accurate to the best of my knowledge, information and belief. Applicant s signature Date: Relationship to Patient For Internal Use: Reviewed By: Date: Income: Medical Debt: Reduction: Monthly Payment Amount: 25% of income= Percentage of Allowance: Balance Due: Length of Payment Plan: months